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tv   Key Capitol Hill Hearings  CSPAN  August 5, 2016 5:30pm-7:31pm EDT

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and we, of course, want to thank everybody who contributed scholarships. there were 16 pre-conferences, including the pepfar implementation meeting that debbie alluded to, tb 2016, enormously successful, hiv, viral hepatitis co-infection meeting, the msm global forum. and so really an enormous number of preconferences. if one real message emerged africa it has to be that it is too soon to declare victory. done yet global aids tuberccloses. enormous challenge to aids is a public health
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threat. i think there is a consensus that it is doable but we really have to be realistic about the obstacles ahead of us. what i am most encouraged about and what i want to share with you now is the fact that there is so much science that it is helping to address those obstacles. so we break the science down, for better and for worse, into five tracks, and those are basic science africa clinical epidemiology and prevention. a big track that includes africacs africa law policy and human rights africa and then implementation science track e. that now is the largest of where we get abstracts from and a lot of that is because africa of course africa the pet farm africa we worked closely birx.mbassador it was a pre-meeting where people work a registered. that brought a judgmental of the implementation science to the conference. track a, basic science, i think
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what we really are learning more about than anything is to issues. vaccines. in terms of the h.i.v. cure africa in a way africa the good have a clearw understanding of what the is.amental challenge and that is the latent reservoir of hiv in the tissues. don't really understand that reservoir. we need biomarkers to tease it out and mark it but we understand that's the problem. for really a wonderful review of where cure science is, the pediatrician at hopkins that did the mississippi baby work, gave an absolutely brilliant plenary on cure africa focusing pediatric aspects of cure. if you have time africa that 20 give you your cure briefing. this is the first time we had a clinical trial on cure and the first try to use this approach, heard of africa shock and kill africa where you theto get the virus out of reservoir and hit it with high
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intensity viral therapy. 100% of patients relapsed as soon as the therapy was stopped. it did not work. but nevertheless, that is how science is. learn from our mistakes. we are a long way to go on cure. andthere is a lot of work environment. better news on the vaccine front. the big vaccine news was the africa which is was the immuneogenicity africa the responses in africans to the next generation of h.i.v. vaccines. that vaccine is basically adapted and built upon the platform that debbie led, rb-144 when she was head of the walter reed program. only successful h.i.v. vaccine we have. to the virusis set africa.ing in the big question, would it be a immunogenic? the answer is yes, the immune responses were vigorous.
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and impressive. go.s a it is going into a phase three trial. the person who has taken on my role as president is going to be the in-country lead for that trial in south africa, so it is in good hands and that is very exciting. i would just say that i.s. put out a new cure strategy, and i think it is a very important document outcome. deeks.d author is steve the man was out in nature medicine the week of the conference. track b is clinical care and clinical science. and this is enormous. i am not going to be able to do justice to it. there were a huge amount of clinical trials, more than 25 trial results, but i will give try to give you the highlights. the first thing to say is a challenge has clearly emerged that is about longer-term retention and care and adherence. thing to start people on therapy.
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it's another to look at how year and two in a years. in a number of populations, what we're seeing is longer term a realon and care is problem. people go off their meds. unfortunately with data from south africa. one of the things about this conference and i think everybody will share your, this really was the emergence of those children were born hiv-infected and have survived. they are the first cohort who had really survived. and youngdolescents adults. they are impressive leaders. they are a magnificent and generation of those who will help us and keep the energy going, but unfortunately they are not doing so well with adherence. so africa for example africa the important south african study africa 5 to 9-year-olds suppressed.irally the older ones only 62% viral he virally suppressed. so there's a drop-off there. a real problem. the promise study africa a large
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ofortant n.i.h. funded trial early initiation with higher h.i.v. pregnant women living with h.i.v. africa spectacular outcomes for women who started therapy and stayed on it but unfortunately the same issue. and post-nursing 23%ca a drop-off of only having virallic breakthrough at year. that is not good. by two years, close to half. that was looked at very carefully and 86% of the time it was because they stopped taking their meds. so that is a big issue for us. there are some really important new treatment advances. the aria trial africa women in the audience will be happy to know. one of the first big trials that specifically looked at hiv treatment outcomes in women with dulutegabir-based regimen africa and it had better africa much lower
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likelihood of resistance and effects.e that is a real advance. the paddle trial was a back to the future idea of taking the medication in combination with another drug and because it has such a great resistance profile, and going back to two dose antiviral therapy as opposed to the three drug cocktail. ant was very much experimental study. only 100 carefully selected participants but 90% viral suppression after year and was tolerated and looked very good. some hope there. long acting injectables, also very impressive. very longhas a half-life in the body that may be an issue with people who well.tolerate it the first trial of injectables, intramuscular injection, this is combination of two medications africa looked at versusek injection eight.
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the four weeks was better. very well tolerated, and this is going to go forward into larger scale trials. so imagine being able to offer people daily oral therapy or a monthly injection. to lookreally something forward to. in terms of co-infections africa hepatitis c were our two big areas of focus for this conference. in terms of tb, i would send you pozniak's terrific plenary on co-infection to say there's a great deal of data there. and dealing with the austral trial. is basically dealing with all the subtypes. we are only doing really well with the one circulating in the u.s. but this looks really great. a 95% cure across all subtypes except for subtype c. africa so we really
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wanted to focus on prevention the data that of has emerged. uniaidsyou saw the report right before the conference africa we are seeing infections in adults globally and increase in some regions -- eastern europe asia.ntral what is the big news there? lots of different kinds of prevention approaches, we saw more data from the vaginal rings that underscore that adherence is a hugely important issue for efficacy. women that were adherent, two thirds protected against h.i.v. of an option. hptno69 africa a prep trial in women. all of the prep studies are inher tonopoveer alone or combination. this is another drug, very favorable looking and well tolerated, safe, and no new infections in women over the
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study.of that a large trial in a key population, the sapphire trial in zimbabwe, almost 3000 women sex workers. unfortunately africa the design was a community randomized to see aat was going difference in offering services to sex workers who didn't show a difference. but in both arms, what it showed africa is that sex workers living with h.i.v. will accept treatment if it's provided in a friendly and environment and they're also interested in prep good.ep uptake was very there was data on prep in a very good population, adolescent men who have sex with men. this is 15 to 17-year-old boys africa htn13. very high incidence in that population, 6% per year. just frighteningly high. it was interesting that adherence was very much associated with kids being concerned that others, if they saw their prep, would think that
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they had h.i.v. and were on drugs. but the good news is it is safe, it is well tolerated, and there evidence ofase of sexual risks or increasing s.t.i.'s. highwere high and stayed africa but still. we have the first data on prep prescribing in the u.s. from gilead, 60,000 to 70,000 people are on it. so that is africa encouraging. four states account for 85% of those prescriptions, california, texas, florida, and new york. somewhat of a surprise. and a majority of the relatively older and predominately white population. so not necessarily addressing where we are most concerned about the epidemic. good news is that there was a terrific hpten study on prep uptake and use by african-americans that have sex 0-7-3.n africa that is the first of the trials that was led by black, gay investigators in the u.s. and
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what it shows clearly is that if there is cultural confidence and an appropriate approach to providing prep that black men want it africa they will use it and they were adhering. was incredibla on the integration of prep and antiviral therapy for discordant couples. the partner study that showed that prep, the way they did it was to offer treatment to the partner who was infected and to offer prep to the uninfected partner as a bridge so the infected partner can achieve viral suppression. a virtual eradication of heterosexual transmission in an population. of those couples, 73% of the time the infected partner was the woman. so this really has an important role to play i think in how we manage transitions and prevention. there was very important data on study.ofofir gel the famous outcome worked and efficacy trial did not work and
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left us all in a state of confusion, what are we going to do with 1% gel? africa the group women lookings of a post session to understand what it did not work. women with healthy vaginal flora, had wonderful protection vigginal stenosis got no benefit. there is not just adherence for women, there are biological factors that we can do things about. it.an treat that was encouraging. there was great data from the on-demand prep. this is different. oral.s not daily this is two doses around the time of sex and two doses after, and you use it when you are sexually active. it when you're not. in the trial africa it showed efficacy. this was the first open label data.
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everyone knows it works and itryone who wants to be on is on it and it has spectacular efficacy. that brings us to a new era which is to say africa how would your prep? intermediate africa daily? us.'s a new question for cautionary data africa as well. very large trial looking at the question of treatment as prevention, the 90/90/90 targets and their impact on incident infection in the communities and the outcome, unfortunately, was it's hard to reach the 90/90 targets. it didn't do well with men. this was a recurring theme of getting men into care. they did well with the people who were on treatment and they did not have an impact on incidents at all. so that is a cautionary note and we were just going have to pay attention to it. track d, our policy, law, legal, economics had a lot of data on
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behavioral economics and incentives. this is a very important area. i think the biggest news was data from south africa that providing social protection -- which people don't like to call welfare but developing countries called social protection -- had a big impact on adolescents living with h.i.v. and improving adherence. the announcement of for lgbt populations. there was the presentation of the johns hopkins commission on drug policy and the implications of drug policy reform. which was trific. it was data from the first really successful method of -- methadone rollout in kenya. africafrica tanzania east africa africa has an epidemic.use
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hptno75 shows you can enroll a cohort of african men who have sex with men safely so that was an advance. a great presentation on new york city's plan to fast-track. the end of aids. finally, track e -- are you all still breathing? implementation science. important area. i said repeatedly we have problems with engaging men in care, so we had a great piece of science. the first result of the search ugandarom kenya and 90/90/90ey reached the targets in the east african population. they got great engagement almost equal engagement of men and women in care. how do they do it? by providing other services to men and convenient, work-hour related times that work for men and providing screening for diabetes.on and non-stigmatized diseases that
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men actually care about. preckia showed importantly in a study looking dynamics in the most affected region in the world africa that there's about eight-year age gap in sexual adolescent girls and older men. and a huge gap in those men in her 20's and 30's getting tested and getting linked into care. this is a challenge for all of us. the big issue for dreams, we can't do better with that age group of men africa we're not advances.ake real there's a lot of information on self testing africa self testing getting out of the clinic africa now rolling out. great outcomes in zam buy with africaceptability doubling the regular h.i.v. testing rate in gay men in self-testing. a lot of data on social media. very encouraging social media engaging msm and india
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care..v. testing and a lot of science emerging on care.entiated models of trying to get out of the model that everybody has to come every month and sit in a clinic all day and get her meds. unforgettable photo of an rural woman standing outside with a sign that says i get hiv/aidsay africa i'm tired of walking." i want to say something about a real change that is happening in the field. relates to pepfar. grateful for ambassador birx's engagement. what has changed is it is always been a key implementer and played a pivotal role in access africa but with the focus on data and on evaluating outcomes and using data to drive decisions africa pepfar is a change agent and that is a huge difference. that really means we'll be able
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to -- one minute remaining and done! amazing. we're going to be able to take and useredible science it to sharpen and focus and tailor the response and in an of what we thought was flat funding but with the kaiser report africa may be declining africa that's critical. can't waste a dollar. we've got to focus and the way is using all the sentence to drive a better approach.ased and by the way africa that human rights approach. that includes key populations. that was a fundamental goal at durban with getting the key populations on the african agenda. i'll leave it to others to say whether we succeeded or failed, but we certainly tried. thank you. [applause] >> thank you, chris. that was amazing. impress tour. africa ambassador birx. deborah: thank you africa chris.
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that was amazing. i were smart enough to say have him go first. i.a.s. forca the this meeting really worked with us. to give three personal reflections. up front, they really worked with us to ensure that our individuals who worked for the u.s. government all around the world had opportunity to share in this experience, to really learn from each other and from others. and for the first time, we were able to get almost 300 plus u.s. government people working on pepfar to the meeting by having the dual meeting, which was a lot of work for them because all were in their space for all the days preceding the conference. there was a lot of trust to let everybody in, but i think it really created that space for us to really share in that global community. and remember many -- remember
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africa most of our staff africa 85% of our staff africa are host country nationals in country working for the u.s. embassy africa so real change agents in those countries and themextraordinary to have there africa see them in the hallway and as part of this. instarted from the beginning the opening ceremony. there was a lot of subtle messages that chris and olive were getting across to us. the subtle message i took home is they had four brilliant, accomplished women singers. they were all soloists in their own right. all independent soloists africa who came together to sing together. allowing each other to lead while they sang backup. and isn't that what we all should be doing? so really looking at that through the whole conference, when should we be the ones singing in the lead and when should we be supporting each other and singing backup? and i think that really has been
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quite extraordinary and talks about the h.i.v. epidemic from the beginning. my second reflection is, we spent a lot of time creating a u.s. government booth, which really shows that all of the u.s. government was willing to voice andher with one one message. the message we had u.s. government was one africa yes africa of u.s. government leadership and how important the was both at presidential level africa secretary of state level africa level.ry of hhs but it also had the timeline that we created since 1981 showing that in different colors. so green was scientific breakthroughs. red was advocacy. and the blue was the political leadership. and showing that all of those sections together is what has created our success to date. and really understanding those three components, advocacy,
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science, political leadership is the real core of the hiv/aids response. which is different from other diseases. i think that is what is celebrated at iaf with the global village and was a to spend almost as much time in the global village as the main conference. because there's a lot happening in the global village. i think my third big reflection is the fact that adult infections are flat is actually saying that things are working. over this've africa last 30 years africa in sub africa where the highest burden of disease is and byare having now 85% 2020 a 100% increase in the 15 risk.year-olds at if you are not going up in that age group, that is the most at risk by that number of infections, that means we have made some progress. but it also points out the groups that we have left behind in the public health response.
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i think we have to be very honest with ourselves where we have succeeded. succeeded in pmcc africa mother to child transmission. thee succeeded because of work that came before us that child built a maternal health block platform to take care of pregnant women and under 5. so building on that, we could be wildly successful. that's why those rates in are downfter country by 85% because mothers come protect their children. you can see that they do not always come forward to protect themselves and that is why we have to work on the retention issues. but we have to be honest that there is not an integrated service forelivery adolescents. there isn't an integrated wellness prevention service for young men that are 25. their interaction at the health center is when they are acutely ill or have had a tremendous
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-- traumatic event. that really shows us that we have been wildly successful where there was a platform to integrate to, and when there isn't one, we're going to have to build it together. and we can build it right together. we can really make this about wellness and health. and we can make living with hiv something you thrive with and preventing hiv something that we all do together. and i am proud of the work that and others have done in the the program that was announced about start free africa and aids free. it is that stay free peace in the middle where we have had the least success whether you are a key population or a young woman. so i think the work that came self-testing africa the realization of men -- and i want applaudone second to ambassador guzby for starting the three combination trials. combinationhree prevention trials at the same
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were starting theirs. and they're expensive. there was a time africa i looked the dollar figure and said oh, gosh, if we're going to do them africa we'll have to do right.ally africa really and we have been working with the investigators all of these years to make sure they were finding men because in every one of these trials africa that was a gap. data isafrica that quite exciting for two reasons. beencha and slim carim had sharing the information with us who.o has been infecting i think that is the other thing that is so extraordinary about aids researchers. sharing with us long before things are published or talked about. and that is how we created the age band for circumcision and tod we have to find 15 29-year-old boys and young men africa get them circumcised so infected. get
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we have to launch dreams for 10 24-year-old young women to really deal with the issue that clearly.d he showed so then we have to find the 25 to 35-year-old young man -- and i think that's what the combination prevention studies africa who are all doing it a frome bit differently, diane havaleer to the botswana project and zam buy africa south africa project. and i'm glad those are still going because we will have an answer of what it looks like when you actually try to reach everyone in the community even know they may not be in the community at that minute. i can tell you, men are never in the community when we are in the community. we go household to household household. they are nowhere to be found. they do not want to be tested in the household with everybody around, even if it is a semi private situation. this has pointed out where we have failed as implementers. and i think that's the exciting thing about being able to use data.
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i have always told the staff, you can get around a lot of confidence interval problems a millionave participants. some not best data. you don't have to have great data. but you can follow trends. you can follow how you are doing very well when you have the volume of program data that we have. this is my shout out to all of the teams because this is not debbie, this is teams all around the world who have worked with partners to get us data in a way so that we're analyzing it together. and i mean together. to really shed light and be honest with ourselves about where we are doing well and where we're not doing well and taking everything that chris fieldummarized to the immediately and try those things thoseey way and look at outcomes. and that is what we are so excited about being a partner in the scientific endeavors and being a partner in that
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implementation and utilizing the data in a comprehensive way. it was exciting to me, but i hope we all learned how when is our time for our solo and when we sing backup for each other. because then i think we impact child marriage. impact first preginancies africa we impact h.i.v. for young women and we have educated africa thriving africa non-pregnant africa non-married aung women that can have successful life. this is really how we can come together in the future. [applause] jennifer:i was smartest to go last. i have to share my thanks, particularly with steve and csis for doing this again. when we first started, i don't think we thought we would be doing this every other year but it has provided such a great opportunity to hear and reflect and share for those who could
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not go as well as those who could, what we all experienced. i want to congratulate chris and anve and owen ryan for excellent conference. for those of us who have worked with them over the years and know what goes into it africa we africaw hard it was thank you very much. and also congratulations to ambassador birx and the whole pepfar team. i have a few reflections to add what they shared and then share about our report on funding and what i think it might mean. obviously, this conference, the big comparison of this was the durban 2000. this is a very different conference, a different time, a different point in the epidemic. so comparing -- there's a lot of interesting comparisons but it a different experience. a few additions to what we heard in terms of the amazing and successful things at the conference. the pre-conferences. them. you mentioned these were amazing experiences for two reasons.
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first of all, there were so many different types of pre-conferences that touched on so many issues. africalooked at names the depth that each one went into. the one thing that was quite different and unique this time but i hope continues is they were really part of the fabric of the conference. so purposefully, they were made to be part of the experience. so anyone who attended those, went to the conference, they were in the same space and it a seamlessted connection between the t.b. focus africa for those who went orthe t.b. preconference cure. a focus on transgender individuals and hiv for the first time, and incredible, very intense focused effort to bring people together and talk about specific challenges and issues and connect that to the rest of the conference. that was amazing. i went to the pepfar preconference just to see all teams come together and talk about their very different challenges africa opportunities africa what accomplished was unique.
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you don't get into that. the important science that we heard. i'm not going to repeat any of it. chris was the expert. there was incredible civil society engagement. great to see. there was a real emphasis on the role that stigma plays in challenging our efforts on hiv. there was a lot a focus by many speakers on key populations, particularly lgbt populations. that might not expect to see emphasis.ong it was there in the speeches and the talks in the sessions very, very strong. pepfar, i want to say couple of things about that. pepfar was ubiquitous in the sense of being an incredible leader and participant at the same time. maybe to your point about being the soloist and backup at the time. they did that well. one thing that i went to a lot pepfar sessions but the dreams africa innovation africa challenge fund africa the the recipients of the award of that.
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just to be there and know those individuals and teams who got the awards just found out that day or maybe even that moment, and came up -- if you were able -- a few of them were able to come up and share what they were going to do and what they are proposed. that actually was awarded. the excitement they expressed, mostly young african women talking about what this meant to be able to go back to their communities and try something different, to reach young women, was really powerful. thank you for doing that and choosing the conference to do it. the last thing in terms of noticeable things to me, there were a lot of new participants. a lot of people i met had never been to an aids conference so it was a completely new experience for them. it was exciting. it made me feel good. i had the opportunity, organized in part by pepfar, to meet with wereal damage staff who there which -- congressional staff were who there which was terrific. one out of all of them had been to another conference. there were new staff engagement from the hill of people who really wanted to be there and were there the whole week. those were incredibly positive things.
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sorry same time africa about this africa with a little africa i have a little bit more of a cynical or murky future.ive on the this picks up on something steve said. i do feel like there was a veneer around the conference of or larger global discussion uncertainty in the world that's going on africa that is just there and sort of loomed out as were all meeting. and what to make of it. i don't think any of us really know. it was this sort of weight of the global state of affairs was heavy that i haven't felta some of these conferences before. this brings me to our report that we released and the pathway is.ard this is a report we have been doing for more than a decade and partnership with u.n./aids. we collect data on donor governments on their spending on h.i.v. and we go directly to the donors because it's the best way to get the most comprehensive
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them so to work with there's no surprise to donors. it is not trying to expose anybody about their funding to say, what are you spending? we work with them and try to analyze it with them. this for an doing long time. we've had blips over time. we did not expect to find what we found this year, which was $1 billion less provided in 2015 for hiv in low and middle income countries than in 2014. 13% drop. there were many reasons for this. some of the reasons are not necessarily problematic. and some are. on the problematic or challenging side, or maybe not problematic just the reality, but the dollar appreciated significantly. why does that matter? when that happens, the currency of other donors goes down. so a donor may be giving the same amount they gave the year before, even more, but because everything is expressed in dollars and that's how the talks about these things africa it made it look
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artificially lower. we looked at that. how much did that explain it? it explained some of it. it did not explain most of it. that was one reason. the other thing that occurred that was a unique situation for the u.s. government is, and this is about using the data and information to do the right thing -- i don't want to speak for pepfar, but we talked with them a lot about this. there was less made available by the u.s. government in 2015 compared to 2014. $500 million less. why was that? the money was there. that money was reprogrammed to be focused on dreams, focused on voluntary male circumcision, and take money from some places and put it where it is to be. it takes a little time to do that for any government. the u.s. amount is actually going to be there in 2016. we expect to see it. it wasn't an actual decrease, it was a delay. we said africa what if we take that out? that out africa it's still an 8% decline.
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we looked. basically africa most governments declined in their and eachs of origin more so when you adjust in u.s. dollars and what was more africa disturbingica of a trend africa is that we have been tracking this over time and we've seen them decline over time. it was just in the past, the us government has been able to make up that difference. so this was a real decline no matter how you looked at it. even accounting for all these factors africa most governments down. why is this? we did not do a survey to ask everyone what happened, but there are some general lessons or observations that we made and i think others have made also. first, we clearly saw shift after the global economic crisis. generally. the world changed. it really shifted. the dialogue shifted. the trajectory shifted the development aid. many governments put fiscal austerity measures in place. that is a factor. more recently, particularly for
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the european governments, they are very focused, as they need to be on the refugee crisis. and that has for several of them placed a dilemma with some countries deciding to shift money and others still in the debate. but that is another factor. that is pulling on budgets. another factor that just emerged is brexit. nobody really knows what that is going to mean. it is not just what the uk's go to do, but what it means for europe and what does it mean in general for the future of the development aid community. another factor, is there less of focus on h.i.v.? is there aids fatigue that we're donors?mong another question, has there been an overly optimistic focus on domestic resource mobilization? we have talked about the need domestic resource mobilization africa that country that is receive aid can do more arewant to do more and doing more but almost to a fault
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on that as a solution. i think those governments, some of the ones we thought were best able to provide more are also struggling economically for some of the same reasons. i have one minute left. looking ahead africa i think uncertainty. of we will have our data before next summer. 2016.g at but before that, a big moment in time is the global replenishment on september 16. the global fund is hoping to reach $13 billion. billione's pressure -- africa yeah. pressures to get there. the dollar appreciation is one issue. this is one marker to look at. beyond that africa of course africa the u.s. elections. i think these are uncertain times and what i feel like back on the conference africa ultimately hope that is the case be a year it could that was a make-it-or-break-it
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when we reach the age of aids regeneration. i will stop there and i look for to everyone's questions and hope we can really turn the corner on this. [applause] >> you hinted at some of the we need to concentrate on. it does seem like coming out of this that for the next year or two, we need a rethink on what kind of high-level clinical oar political strategy are we going to pursue. the u.s. is the dominant player today. two-thirds of the dollars are u.s. dollars. that's a dangerous position for us to be in. an e.u. inget past disarray and the u.k. exiting and losing their capacity to africa keep capacity. we are in our own transition. we had you in agency to leadership positions turning over. that can be both dangerous and also the opportunity to make the case.
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i would add to jennifer's notion africa have people become complacent? i think also we have a confusing set of messages to the american public. i think part of it is what we are telling people they should think. complacency ist around a bit too much hubris around the success that lies or soon around the corner and it gets people to urgenthat there are more and pressing things and that we can half off a little from here and a little from there and ease like.d the i would also add because the conference took place are you currently republican convention it got somewhat muted coverage although the coverage bad.ot it might have been more of the broadcast media attention if it had been timed somewhat differently. that is just the way things are. at maybe you could all say bit about if you're thinking
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aoud now about what is to try tohat's going high-level political interest in this africa renew budgetary interest. get people on record technology this which seems to be one of pieces.missing my fears we are in a turbulent and transition year and then we get through that and then i continue to be likely turbulence and transition of new governments and new leaders and we might get anotherrdam and have major setback africa continued absence of high-level political this.ship interest in what can we do in the next 6-12 month in your view that try to reverse those trends? deborah? deborah: i think two things. that we haverk been doing with the global fund has resulted in none of the u.s.
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now in t.b.rograms africa h.i.v. or malaria africa can be successful without an enormously successful global fund replenishment. we've spent the last two years every singleg thing to make sure every dollar has the maximum impact. because the issue of the currency, a lot of the real dollars in the country were less. mark and i have really worked country by country, site by site -- and one of the reasons we mapped every single pepfar site down to the site level, thousands of sites every single place, is to really made clear where we are, where we are dependent on the global fund to where we are, which is 100% and most of our sites. so in most of our sites, the global fund is either providing the commodities for testing or the commodities for treatment. all the first-line commodities treatment. half of the bed naps.
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many of the mdr treatments, and gen experts and those commodities. so whereas pepfar and pmi in the tb money may be working very closely with countries on service delivery, the majority of our commodities are coming from the global fund. so can't have one without the other. i think we have done an enormous job in de-duplicating and making ourselves dependent on each other but now we are completely dependent on each other so i think that's really an important thing for the american people and the american congress to also every single donor so that they understand when they invest in the global fund africa they're investing in the ability to leverage the 65% the u.s. investment that we're all making collectively to pandemics.hree i think the second piece is, sometimes we have to be willing, again, to sing backup. i think we have to be able to
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show and bring together the groups that are interested of sexual preproductive health for young women africa edgefor young women africa interested in marriage early pregnancy africa and bring those groups together as well as the groups that are interested in human rights and understand the interface between public health programmingealth for lgbt and human rights and bring their voices back to the table. because we have to have a larger message. we have to be up to use each other's indicators. we are in discussions right now, how do we measure whether we are impacting teen pregnancy, child marriage? how do we measure lgbt has access to preventive services, to treatment services? so together we can integrate our messages in a way -- we talk about integrating program. have to integrate our
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indicators and messages so we can show how we're leveraging impacting each other's goals.development sustainable development goals. i'm never going to get that right. there are 17 of them. we have to start utilizing each other's indicators so we can show we are not only having an impact on hiv, we are impacting these other social determinants key.alth which are really i think that's on us to figure out how to do that so the american people and congress what they invested in the global fund and pepfar has deal with able to maternal child health africa immunizations africa ebola and potentially the public infrastructure to deal with other global health security threats. >> chris? chris: that's a tough question. let me say, first of all, one of the efforts we invested in to
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try to get back on the global agenda in a way was to have a lot of high level, high profile people be with us. and from different sectors. on that level, we were spectacularly successful. it must be said. africa in the opening charlize theron africa sphran gavess africa who actually a great talk. bill gates, very important for the people within the foundation working on hiv to maintain his interest. obviously, the private sector support is huge for specifically the research agenda and many of the things we need to do. he came africa he was very engaged. we had an extraordinary moment where elton john and his husband david furnish were there. they announced this new initiative with pepfar for lgbt people. but in his session, he essentially handed on the advocacy torch to prince harry. and prince harry, you know, who is from u.k., by the way, a
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country that we absolutely need to stay. when you look at the actual global donor base, the second after us is the u.k. they are a critical partner in this. so his engagement around aids and connecting it to his mother's legacy is very important for us. we had, for the first time, really ever, the un's secretary-general ban ki-moon. nevertheless he came. he was very engaged. having those kinds of folks be there and participate with us really does help. i will tell you that on the opening of the conference, the single biggest news item was charlize theron. not my prep science africa i that is.w why what are you going to do? wem that perspective africa were successful. a lot of the success has to do with people's commitment to
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africa and how engaged they were. of durbana the legacy i think was meaningful to people and the enormous sense of epidemicround the continuing. in terms of the global fund replenishment africa right. that's absolutely that that is the central and we are very heartened that it is happening in headed a interested to know -- justin trudeau seems to be committed and engaged. that is great. there are a number of donors who are stepping up. i do think that one of our goals was to change and nuance the messaging around the likelihood of success and the urgency of this moment. there had been, i think, an overemphasis on basically we have won the fight. well africa we haven't won the fight. we have achieved an incredible understanding of what we need to do and we have an amazing number of scientific tools in place and we have community support to do it, but it is very much a make it or break it moment. and that message needs to be out there, that we have not won the fight yet.
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it is much too early to back away. i think we succeeded in changing that message. >> i do think here at home, we don't need to rely on others. i think we need to be blunt in the appeals to the clinton campaign, to the democratic and republican leadership. there needs to be some kind of reformulation coming out of durban of what's the problem we're facing here in the next concrete and fairly appeal as to what they should do. i agree having bill gates there was absolutely invaluable. having charlize theron, prince harry. those people can be brought in. i think it is to be a europe strategy and one that gets african leaders reignited and speaking. in the absence of them speaking, it is really hard to make the case. make thely hard to case. in the midst of the refugee crisis. right? and half of the refugees that are coming to europe are
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emanating from broken african states. and they are coming across under the worst and most cruel circumstances and dangerous circumstances. so that is dominating a lot of this. on the american front, jen, you guys have been carefully tracking opinion in the united states. maybe you could say a few words about how do you when you look out on the american opinion environment, we're in the midst of this unprecedented turbulence and we're not sure where it's conclude africa but on these issues africa where does that sit? jennifer: we have been tracking u.s. public opinion on h.i.v. africa on global health for many years. i say in general, and there's a lot more nuance in the report, but in general, the public is supportive of u.s. engagement in the world. and we saw that just a few months ago africa despite sort africapolitical rhetoric a few months ago africa that was still the case.
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we'll still be polling on this. we will report back if that changes because we are still -- the public seems to get that our role in the world of global health, hiv matters. it is morally important. and that is a driver for them. but we have seen two things. one is less attention to hiv among the public. they do not see it as a big problem anymore. they don't see it in the news much. that is one trend we have observed. we have also observed a growing partisan divide on some of the support. so there still general support, but when you look by party identification or ideology, there is always been differences, but we are seeing those differences starting to more. maybe not a surprise, but those say to me, the larger climate is spilling into the support for global health and hiv. and also this issue we have all brought up around waning attention. people are not seeing it in the news.
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people are hearing mixed messages around are we successful africa are we not africa what do we need? we see that i think in public support. i want to say one thing about, you asked what needs to happen. just a couple of thoughts. agree that the messaging has been really tough. when i think back, if you think of it this way, the first 15 years of the epidemic, there was really no hope. there wasn't anything that worked. for the most part. i'm exaggerating to make this point. it wasn't until 1996 where there was something that people could hold onto, and it wasn't until 2000 when there began to be a change globally that the epidemic in africa had to be a priority. so for the first half of this epidemic, there was very little to hope for. then all of a sudden we were in a different place. i think there is a tendency to grasp onto that and hold onto it because it is so important -- but i don't know the best way -- maybe we need to retell the bit. a little
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retell it and the dramatic story africa ie is to tell don't think -- we've done it recently in the way people need it.ear the other thing is africa the single most -- there's so many made thehat have response to h.i.v. what it is and how unique it is. the single factor that is so different is civil society and aids activists. that is the bottom line that is what makes this epidemic different than every other and see.s what we need to that is going to help change the mood, the trajectory, the is thence africa engagement of aids activists. >> let's open it to the floor. early interventions. we have two hands here. dean, over in the corner. we're going to bundle together, so hold off. identify yourself. >> my name is anna forbes. i'm an independent consultant based in d.c. i wonder if you could talk a bit more about the significance of
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abdul kareem data looking at bacterial vaginosis and its in heightening h.i.v. risk. we know from u.s. data there is a correlation between bacterial vaginosis and the economic status of given populations of africa especially among black women in the u.s. so doesn't this suggest that improving the economic status and vaginal health among women has a direct or might have a direct effect on reducing hiv risk? >> thank you. and up front. dean? peter. >> yes, thank you for the illuminating conference. >> arista. excuse me. yes? hi africa i'm indy riser havea i'm a socialist and worked in the developing world. a question about the role of some of the u.n. agencies, the u.n. population fund does a lot of work with reproductive health
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maternal health. say a little bit more about w.h.o. ban key moon was there. what about the role of the world ofk and the man who's head it being a physician. made?mpact has that >> thanks for bringing the panel together. it is a real public service to all of us to have this opportunity and thank you to all of the panelists for the great work that you do. a question specifically for ambassador birx but i'm anybody's in response. incredibly impressive gains in pepfar and commit and treatment and in circumcision. debbie, you have impressed upon me about the population growth that's already been mentioned today. that half the population growth by 2050 will be in africa and population of africa will double in that time. given the great success of pepfar with a focus on targets and data in the rigorous
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implementation africa has there discussion or feasibility of bringing reproductive health -- you mentioned this but more close to rigor in terms of that and focus on data? it seems like such a great a greate and such successful model of pepfar. >> there will be another opportunity. we'll get to a second round. we take a fourth one and come back. our speakers and do another round. yes africa please. >> my question is, what indicators is pepfar using around gender and hiv? are you using the indicators around gender norms, gender-based violence, age? disaggregation? how are those playing out? and with the decline that jen talked about with the importance of civil society yet all the groups they talked to in durban
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from civil society are saying their funding is going down or evaporate. jen africa particularly would that?mment on we comefrica why don't to you first. several were directed to you. >> let me integrate them because i think they have a common thread africa the four questions. part of the dreams work we're doing is dealing with what you africa the social determinants of health and meeting the young girl where she is. that mean we have to have done? all of our interventions are directed at specific age groups, realizing specific age groups need a different approach. so we have a 10 to 12 africa 13 to 19.frica 15 and for those of you who are pepfar implementing partners and don'tpologize apologize that we are collecting everything by age and sex and we reallyted so that understand who we're reaching and who we're not reaching.
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it does point out precisely how chris started. we're not reaching the 25 to 35-year-old men who unknowingly are transmitting to the younger women. i mean unknowingly is that no idea what the status is. when you take slim's data any project that across the entire global program, and particularly in africa, 780,000 new infections every year are being driven by that. 25-year-old infecting a to aar-old who grows up 20-year-old who infects her partner in a discordant relationship. 23% of the discordant positives are women. because they got infected by the age group that is not being measured anymore. now they are 40. this is exactly why you have to bring in the social determinants of health and really meet women where they are. and the first thing young women say to me no matter where i am, i want to know how to not to be pregnant.
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so that is when you really understand that you have to -- you can't approach a young woman if that is her concern. saying, why aren't you worried about hiv? that is how i started it. i asked one in four africa you risk. high i asked you about how to keep from getting pregnant. that is what i'm worried about. ok africa yeah africa that's what we and i was, like, ok, yeah, that's what we have to do then. so we are really working with groups to really make sure that we have all those pieces available to young women. and then you get back to, where do you do wellness and prevention for young women, because it isn't in the current health care system which is highly stigmatizing? we have to be honest. young women who try to go to clinics for reproductive health commodities are turned away and told, you should be going to church, not worried about getting pregnant. so we have to understand where we're working and make sure that we're dealing with those cultural issues at the same time. and so all of those pieces and
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all of our investments that we're making -- now, this $400 million that was part of this set-aside that took us a month to plan and now it's going out, it is really critical because it's really about prevention, but it's not about solely prevention messages. it's about meeting the young women at their concern level and addressing those, but addressing them within the framework of dealing with the community and dealing with the family. and panel after panel that was there at ias kept coming back to, you know, we have to work within the cultural framework. yes and no. if girls are being trafficked in their communities and a third of them are being raped, we have to be very honest about what's putting young girls at risk and not accept that, just like we haven't accepted gender mutilation as a cultural, acceptable way to go forward. we can't accept rape in the
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community as anything but inappropriate. and so these are the kinds of tough discussions that we have to have because young girls are essentially being trafficked within their community for many reasons and we're finding those out within dreams. but that's what i was talking about when the tent has to be bigger, because if we really want to prevent -- because we agree with jen. this is not a given. with the youth wave and the still-unrelenting risk to young women and what is putting them at risk and what's putting key populations at risk, this is not a matter of, you know, taking the tools and saying they're here, come get them. it's going to be a much more difficult road. and i think that's what we're in together and that's what we have to have solutions for. and i just want to thank csis and others, particularly janet fleischman who's been out there reality testing everything that we're doing and getting back to us and saying, ok, you said
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this, i talked to them, they said that and now we've got to fix this. because we really are all in this together and we have to constructively figure out how to make this better. steve: chris, can you say something about the caprise vaginal biome project? dr. beyrer: yeah, yeah. so i think it's important to understand that actually where that special session that was put together had three different data sets in it. so if it sounds like we're talking about somewhat different things, we actually. one was this analysis of linked transmissions that really showed the age gap and what debbie just alluded to. the other was this analysis of the microbiome and vaginal flora. and just to be clear, it didn't show an elevated hiv risk. what it showed was a dramatic decrease in the efficacy of the tenofovir gel. so it just didn't work for women, they didn't get any protection from it if they did not have a normal, healthy vaginal flora. and the women who did, actually the protection was in the 65 or 68 percent range. so a really impressive split and that paper is just about to be out.
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i think it's coming out in new england journal. and you can see, for those of you who are epidemiologically oriented, the kaplan-meier curves diverge and stay apart. it's impressive. and it probably does point to that mechanism. so that's partly what we're talking about. tenofovir gel, the 1 percent tenofovir gel as a topical microbicide i think now remains a tool that we need to understand. the phase three trial was disappointing. but this suggests potentially a way forward. and i think that's why it matters. it's still a research tool at this point. i think that, to some extent, is true with the vaginal rings as well, that we really need to understand a lot more. steve: thank you. jen, on civil society? yeah.
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so i think jill asked the question, with funding going down in general and my saying civil society is going to be critical here, and always has been, what about funding for civil society? unaids and funders concerned about aids and a few others have been looking at this and raising this alarm, in a sense, that funding for civil society engagement is not there. it's less than it's been. it's not an area that's been invested heavily in. so how can the global community, you know, get a bigger focus on hiv without a strong civil society? and i think there's a lot of ways to engage civil society. pepfar has already done it in a very meaningful way in the last few years by bringing civil society in. but i think in terms of direct support, it's a key issue that came up at the conference. it was raised a lot in durbin. and i think it's just an ongoing one. so going hand in hand with civil society engagement is supporting civil society in a whole variety of ways. so i completely agree with that. deborah: so while you're getting the next question, let me just make a quick comment on that because, you know, we put out
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our dreams innovation challenge and it was $85 million and for the first time. and for the first time, i mean, pepfar's put out $70 billion, the fact that we got 48 percent of the new individuals having never received pepfar money and many of then small, indigenous organizations led by young women was very exciting. but it also caused us to give pause about really, how should we do the key population investment fund? and so we really will create tiers within that to really create opportunities for our groups to apply that are under 25 where they're competing only with under 25 groups that have never received hiv, pepfar or global fund dollars to compete in their own group. because people who have competed for other grants write the most beautiful proposals, so we want to be able, if we're really serious about bringing on additional groups, and we're really exploring about having the groups apply in their native language and us doing the translation, because i think that will really open it up to really do what you've talked about. steve: before we go back to questions, just one point on dee's question about who.
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i think it's terribly important to think about what the next leadership will look like at durbin. philippe douste-blazy, the head of unaids, a frenchman who's a candidate, declared candidate, was there, he came to the dinner that we hosted. i'm not sure what public positions he took on any of these matters around if he's elected what would this mean. but the fact that he was there was quite important. dr. beyrer: yeah. steve: ren minghui, who came in in january from beijing out the ministry of health to head up the hiv, tb and ntds division as an assistant director general, was there, was very engaged.
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i think that's promising. i think there's a lot of decisions that lie ahead on priorities and the way in which the u.n. system is going to be examining its structure and sustainability across multiple agencies in this next period. and there's a lot of talk about that. i'm not sure what to make of it, it's a little bit beyond me. but that could have impact on keeping the key eye on these issues. why don't we open again for another round? we've got two women right here. we'll come to nomonde. >> hi, good afternoon. my name is anna maria and i'd like to first of all thank all of you for being here with us this afternoon. my question is to the honorable ambassador birx and it is around couple's voluntary counseling and testing, cvct. this intervention has been proven highly effective across sub-saharan africa. studies have shown two-thirds reduced transmission of hiv infections in (inaudible) discordant couples across sub-saharan africa, also cost-effectiveness and, perhaps most significantly, cost- effectiveness when it comes to adherence to arts with cvct as opposed to individual vct and also improved adherence overall.
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so my question is, what is pepfar's take on cvct? and also, what do you see as the greatest challenge that pepfar faces to supporting the development of national guidelines for cvct? thank you. steve: thank you. right here, right here, arista. right there. >> thank you so much for a fantastic discussion. so i'm very glad ambassador birx mentioned, you know, the role of collaboration and synergy for improving health outcomes. so, you know, when i hear about hiv, the one example that comes to my mind is botswana. you know, one of the first countries where antiretroviral therapy was rolled out. and recently i read an article where the health minister mentioned that the women they have saved from hiv they lost to abortion due to, you know, lack of family planning or cervical cancer. so my question is that, you know, with the changing scenario, you know, increasing conflict, climate change leading to more gender-based violence,
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which also has implications for hiv, do you see a future of the hiv community and advocacy to work with health system strengthening and sort of vertical within the horizontal to improve health outcomes, specifically hiv outcomes with health system strengthening? so that's the question i wanted to ask. thank you. steve: thank you. thank you. nomonde nolutshungu, health attache, south african embassy, thank you, nomonde, for being with us today. >> thank you, stephen. thanks once again to csis for this debriefing session. i'm particularly proud to learn from all of the people who attended the conference that durbin actually delivered on the objectives of the conference and was able to learn all of these things from yourselves presenting here. it seems to me that going forward we need, as we think about messaging, we need to demystify the science of this
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disease so that we build confidence in communities about understanding the actual science of this disease. and as we do do so, i take the point about not touting too much about successes. at the same time, too, we need to strike the balance that is not going instigate fear and therefore leads to stigma and so on. so we need to strike that balance. and part of striking that balance is demystifying the science. there's a conference, the one that comes in between these conferences, the scientific and pathogenesis conference. i think if we did a debrief on that conference, the intelligence of science is actually being able to communicate the details of what is coming out of the science. a lot is known now and a lot still needs to be known. you know, the dark spots and so
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on. i think we don't know who might be sitting in the audience. it might be some (inaudible) some scientific (inaudible) who are not necessarily interested in these things. but as they get to learn about the science of the disease, they might assist us just to fill in the gaps and the blind spots in the science. so demystifying the science and debriefing from that conference, like as we're doing today here, i think would be useful, steve, in going forward. congratulations to deb and to south africa for hosting a successful conference. congratulations to you, chris, for co-chairing with us on that conference. thank you. steve: thank you, thank you, nomonde. [applause] right in the rear there, arista (ph). please identify yourself and be succinct. >> hi, very succinct, melissa sharer from jsi. i'd love to have a little more information about the postpartum and the retention issues (inaudible). we've had a lot of success on pmtct, so what's happening there kind of under the ethos of bringing the science to the field? steve: thank you. chris, let's start with you on
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the science issues that nomonde raised. dr. beyrer: sure, sure. so i think the very important trial data there which i would point to is the promise trial results. that's a large, multi-country nih-funded study. judy currier at ucla is the overall pi. there were several different abstracts presented and papers presented. you're going to start seeing those and promise jointly with impact. so there's several things to say. first of all, the pmtct outcomes were outstanding. so there's no question that that worked. the idea of basically the promise concept was a randomization of immediate therapy versus the standard of
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care which was, you know, doing cd4s and delaying therapy and seeing what that did clinically for mothers and pediatric outcomes. there's no question that the women who were randomized and started therapy earlier did better. and the clinical outcomes were halved. so that is absolutely great. the challenge is that one year out postpartum, 23 percent of women were not virally suppressed. so there was a drop-off and in an analysis of those women, looking at very important question, because there's several reasons why you would not be virally suppressed, and one is, of course, you might have resistant virus. but the most common reason is you stopped taking your meds and it turned out that's the reason. so 86 percent or so of those women had broken through because they had stopped being adherent. and it looks as though mostly women were adherent through breastfeeding and they got the message that they needed to stay on therapy through lactation, but then there was a big drop-off with weaning. there are a number of issues there. and one of them, you know, both debbie and jen alluded to, and steve as well, which is the whole issue of stigma.
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so doing things for your baby and for a healthy outcome is very, you know, culturally and socially supported. but then if the baby is healthy and hiv negative and doing fine and you're not breastfeeding, why are you still on those meds? then you get into a different dynamic about disclosure and the fact that you yourself are living with hiv. and those challenges are out there. so i think promise points to the power of early initiation of therapy, why that's so important, but also the challenges with uptake. so this is a sea change for us, right? we started, as jen was alluding to, early days we tested everybody, looked at their cd4s. and people will remember, when you had to have an aids-defining illness or below 200 cd4s to get therapy. in burma, a country i work in,
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actually there was so little treatment slots they went down to 150. so people just had immense immuno compromise before they could start, right? well, that turns out to be bad medicine, right? so the start data, which were released in vancouver, early initiation of therapy, getting rid of this whole idea that you have to stage people and saying if you're living with hiv you should be offered immediate treatment, reduced mortality, the ultimate endpoint that we all care about, and it reduced morbidity and it reduced malignancies and it reduced tuberculosis. i mean, it really worked. the problem is now you're talking about offering daily, lifelong therapy to people who are healthy and asymptomatic and have never had an aids complication and have 800 or a thousand cd4s. and it turns out uptake is
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lower. so in promise when women were offered immediate therapy, the uptake, what changed in that study i should say is while they were well into it and enrolled several thousand women, the start data came out, so that changed the ethics because now you have the evidence, you really have to provide, you have to offer everyone therapy. so what was the uptake? here's the data that you should start therapy right away, 66 percent. so a third of women diagnosed with hiv, pregnant or recently delivered, offered immediate therapy in a setting where there were a lot of services, a lot more than in most clinical settings, still a third of people said, no, i don't want to do that. so that's a big problem. steve: deborah, do you want to add (inaudible)? deborah: so what pulls a couple of the questions together is this, when you think about vct and you think about messaging, imagine what we've done over the last 15 years. we had, we just talked about the index cases and those cases are the women. so their cd4 is lower. the young men were more recently diagnosed, so their cd4 is higher. so for the last 10 years, we've been saying, ok, woman, if you're pregnant or you have less than 500 cd4s you need to go on treatment.
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we've said to the men you're fine, you don't need anything. now, that is a very confusing public health message, particularly when you want couples supporting each other in retention and adherence and how important that is. but now through start and through promise we have a new opportunity where we all can say the same thing. if you are hiv positive, it's detrimental to your health and you can transmit the virus to others. and that's our single message. it doesn't matter if you're 2 years old, 15 years old, 25 years old, 85 years old, the message is the same. it's not dependent on a secondary measure. and i think that allows us to be much more effective in couples vct because it did result, and what was brought up by another question, some gender-based violence and other pieces when men couldn't understand they had the same disease, but weren't offered any treatment, and really figuring that out. so we certainly support couples vct. we don't want hiv to be stigmatizing to the woman because we haven't found the man.
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and i think we're working equally hard on trying to find men and getting them engaged. and the one place we know men and women are all the time, or at least every sunday, is the church, and going back to the churches and saying it's really important for everyone in your congregation to be tested and have access to treatment. so we're going back to the faith-based community and saying help us tackle this problem of a lot of men being undiagnosed. because you can't start going to every bar or every gathering place or every farming convention to find men. we have to find men in a much more effective way. and thank you for the question from botswana. so this really gets into how important leadership is. so president bush obviously started pepfar, but then also went on to pink ribbon red ribbon for cervical cancer, because he really saw what you saw in botswana. and so that's been a big investment that pepfar has been supporting, is addressing cervical cancer prevention, primary and secondary prevention and test and treat for women that are positive. but i think it also illustrates the importance of secretary
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clinton bringing in the gender-based violence piece. so she started us on these violence against children surveys. i think we only got two done while she was still secretary of state. but we've now done 11. and what's been enormously consistent is that between 25 and 35 young women's first experience with sex is forced rape. and that in their lifetime experience, this is asking 24-year old, in their lifetime experience, 40 percent-plus experience sexual violence. so this is an issue that we really have to combat if we're going to end this epidemic. and that's why i keep talking about how we really do need everybody at the table.
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and thank you for talking about demystifying the disease, because i'm going to call on you now to do one of those global health diplomacy pieces that we talked about, getting chris there and olive and others and let's have this discussion with the diplomatic corps here about the realities of hiv and help them write the cables homeless so that they can get to the foreign ministers and the prime ministers and the ministers, and let's do that together. because that is on us and we have a mechanism to do that with that other hat. so thank you, that was a perfect question. steve: thank you. let's take one more round of questions. we'll come back and then we'll move toward some final thoughts. right here and right here, please? and then david. please identify yourself. >> my name is (inaudible) i'm with hhs office of global affairs. my question is focused more on the general decline of donors' support. so, you know, it was kind of piggy-backing on the botswana question. but how is, you know, with the increasing role of the private sector in africa and africa's development, what is the role of
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the private sector? how was their reception at the conference? i mean, what are some of pepfar's engagements with the private sector? and what are some issues to look for moving forward with engaging private sector? thank you. steve: thank you. and right behind you there. arista, right there behind you. thank you. >> thank you. hi, my name is yvetta gonzales, i'm with cardno emerging markets. and my question is, when we look at non-detectable status in a few communities across the world, we now see rising epidemics of syphilis, chlamydia, gonorrhea and other stis. in the future with pepfar, either (inaudible) site, at governance level or even grassroots level, are we looking at changes in education, awareness? and is there going to be funding surrounding those kind of changes in behavior? steve: thank you. arista (ph), over here with david bryden. david, put your hand up. thanks. >> david bryden with results. you know, durbin was an unforgettable experience, particularly coming back to what jen was saying about the power
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of activism on display, just absolutely extraordinary to see that in motion. and, you know, just one of the things exciting for me was that recurring theme about the enormous risk that people with hiv are facing because of tb and aaron motsoaledi, the minister of health, coming back to it again and again and again. but i had this experience. i was handing out stickers saying "where is my ipt," isoniazid preventive therapy, and i would get again and again and again people saying, what are you talking about? you know, and this is a really important daily antibiotic to help protect people living with hiv against tuberculosis, on top of art, of course, which is super, super, super important in itself. what can we do to get more tb literacy, a basic familiarity with tb? and where are we in terms of
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pepfar tracking the implementation of ipt? steve: thank you. do we have any other hands over on this side of the room? right here. >> hi, krista johnson from howard university. i had a question. i wanted to know about traditional health systems and the role that traditional healers played in the conference, but also how that was highlighted. i would have expected, coming out of durbin in particular, that perhaps now would be the time that we would see more of a coming together of the scientific community, western scientific community, and traditional health systems. so i wonder if there was any movement on that.
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steve: could you just hand the microphone over here next to you? and then we'll come back to our speakers. yes, please. >> rob lovelace, trade union sustainable development unit. i take the point about reaching men and would suggest or perhaps get a response on the possibilities of expanding hiv prevention in the workplace. steve: thank you. let's start with you, chris. we'll move down the line. dr. beyrer: ok. well, just quickly to respond to that, i think search has a focus on doing that, precisely doing workplace-related and trying to get the men where they are. and i think debbie hit exactly on the issue, you know, that so much of our success was built on the maternal/child health platform which just doesn't speak to me. so that is something that we really, really need, i think, to rework. i would say that the traditional healers, if they had a voice, mostly it was in the global village and the cultural competency context. they're important allies. i will say that in south africa there's a bit of a challenge there because remember that this is a country that went through a long period of denialism and
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where there was a lot of nonscientific herbal and nutritional remedies put forward that were not remedies. and so it's more of a fraught issue there than in many other settings. we know that they're important cultural allies. we also, you know, you really have to balance that because, you know, beet root doesn't work and antivirals do. and that's the reality we're dealing with. i also wanted to just get back to the point that was raised about the private sector, and it relates a little bit to something i think we need to be mindful of in terms of particularly the global fund and beyond africa. and that is that this issue of the funding gap and the concerns about the global fund have a particular relevance for middle and higher-income countries, right? it's different because that's where we're even more worried in some ways.
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and there what we're seeing is that as the global fund has withdrawn from a number of those countries, governments are not picking up the programs that really are essential for their epidemics. and by that i mean harm reduction, methadone, (inaudible) and substitution therapy. right? eastern europe, central asia, particularly russia and ukraine is where hiv is expanding most rapidly in the world right now and where the withdrawal of those resources is playing a very important role. so it's very appropriate, because durbin was in africa, that that has been the focus of our conversation today. you should not forget that it's a pandemic and it has some hot spots that are really in trouble. and i would just add, speaking on behalf of ias, that this is a major focus for us for amsterdam 2018. that's where the next conference is going to be. in our first conversations with the dutch, actually when we were competing and making the decision between amsterdam or san francisco -- apologies to folks here -- this was one of the issues that they raised, that, you know, the western europe is doing great in its hiv response, eastern europe is deeply flawed and that they were interested in helping with that problem. so you're going to see more of that and you're going to see that focus coming forward in amsterdam. and i think that that's going to be very important.
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they've already appointed a special envoy. they already have people out working in the region, trying to outreach. they're going to invest in this in a significant way. steve: thank you. deborah? deborah: so i think (inaudible) in the private sector, we've been very privileged in getting a lot of private sector support in our key initiatives. and certainly, dreams is taking advantage not only of the incredible wisdom that the private sector is giving us on how to really create a brand around young women that people cherish and value, but also their insights into how to sell things to young women because we want to sell a wellness message, we want to sell a message of empowerment. and i think that's been very exciting to us. and they've been financial supporters, whether it's johnson & johnson or gilead or vive (ph) or the gates foundation or girl effect. so that's been really central. and we have several other public/private partnerships that are really key. but i think an important piece, csis just did this great piece
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on this, and i think really pointed out some of the issues with that, particularly if they're one-off, they're not continued, how are they sustained, how do you convert that into really investment into those programs and into those countries for that long term and what should that look like and how do you achieve that and how you negotiate that up front. so this is really exciting. i think dreams gives us an opportunity to do that. we're looking forward to figuring that out. ipt -- we have a terrible ipt indicator which ended up just being people ignoring it. so we are going back to the drawing board because we think you don't manage what you don't measure. and so we really have to figure out how to measure this in a way that is relevant so we can really tell where the gaps are. and we couldn't agree with you more. traditional healers we used, we've really used traditional healers in the rights to passage and voluntary medical male circumcision. they have been extraordinarily helpful in demystifying why voluntary medical male circumcision is important and
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understanding how it's not threatening their rights of passage, it is a right of passage that can still be accomplished, but let's do it medically correct. and i think they've been really helpful in all of that. and certainly, we are doing a lot of hiv prevention in the workplace, but we still have a lot of men in very informal work situations. and we're trying to really figure out how we reach them both there, but also in the workplace. in many of the countries, botswana being one of them, obviously people are crossing borders to go to work. and so that really -- and most of the public health programs in the workplace are funded by the governments and governments have really seen this and have been really open to providing cross-border support to those individuals and providing art and other things in the workplace. so i think that's really
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important. and governments have really stepped into that gap and have been very good partners with us on that. steve: jen? jennifer: yeah, i would just add one thing on private sector engagement. you know, private sector has been engaged and important in the global hiv response for quite a long time, for a majority of the years of the response, especially if you widen it and include foundations, but, you know, companies. and pepfar has numerous examples of how private sector has been able to, you know, do innovative things, partner. the global fund has them. i think it's just being realistic about that means with the funding gap. what is the private sector realisticallgoing to do? i still think the role of the private sector in general is to provide innovative pathways that can then be taken up by governments, supplement, fill in gaps, but i'm not sure it's the answer to this bigger problem we're facing. steve: we're getting towards the close here. i'm going to come back to the three speakers to close with just a minute or minute- and-a-half around how you think this durbin will be remember. you know, what will be the signature terms that people have
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in their minds when they think about this? you were the maestro, chris, so you've got the closest grasp and you've been involved in these, as has deborah and jen, for many years. what do you think is going to be distinct and different and jump out around durbin? dr. beyrer: well, i think first of all you have to say how transformative the global engagement around hiv has been. so we cannot escape the narrative that when we were all there in 2000, at least for the folks who were there, we were looking at a human, moral quandary of available therapy that was unavailable where it was needed most and an incredible impact on human lives. and this movement turned that around. and it really is extraordinary. and in durbin we celebrated 17
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million people worldwide on antiviral therapy. that is a huge achievement. and the scientific achievements have been extraordinary, the scientific investments. so i think, you know, we all gathered and understood that it really is a different world. and we're less than halfway there. and i think what we really wanted the messaging to be around this conference, and i think we achieved it, was to try and re-galvanize and reenergize the movement around saying we are not done, this is not over, we have an extraordinary road to go and we need the world to keep focused on the success and the amazing achievements that we've done so far together as a community and don't take your foot off the gas. steve: thank you. deborah? deborah: you know, i think it will be remembered for two things. one, the stock-taking reality of
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really knowing where we've been successful and where we had this huge gap. yes, 50 percent on treatment, but less than 85 percent of young women reached with prevention. that's having an impact because we've only had a 15 percent decline in new infections in young women. but the hopeful thing to me and i think what will be remembered from this, and i want to thank chris and olive and everyone who put this together, to have jake glaser there, to have the elizabeth taylor grandchildren there, to have prince harry the son there together saying we have to address this, to have nelson mandela's grandchildren there and say, you know what, we're willing to step up and also carry that torch. i'm just remembering. i see sandy thurman back there. she was the head of the u.s. delegation in 2000 to durbin, working for president clinton. you know, we are getting older, sandy. [laughter]
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so it was encouraging to sandy and i to see the next generation willing to step up, because we're not talking about something that is completed in five years, we're talking about something that's going to take us at least 15 years by the model, but that means we still will have 25 million people who will need treatment for the next 50 years. so we're talking about a century to really understand how to end the whole disease. so seeing the next wave and seeing their passion, like their mothers and grandmothers have, it was thrilling to me because you want that passion carried in the same way. that's why the rest of us get up every day and don't sleep because we know that this has to be done. and to see the next generation, that may have skipped a generation, but close to the next generation, step up and say we're happy to carry that torch with you i think gives me great hope what's possible. steve: thank you. you get the last word, jen. jennifer: i would just add to that, i also would say it will
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be remembered for extraordinary african engagement. and, you know, maybe it wasn't already at the leadership level, but there was a lot of civil society participation, a lot of scientific participation at a level that i did not ever experience. so that's incredibly powerful, so that was one. i think we've all said it, this sort of wake-up call, i think that message that this isn't over has come through and this is what durbin should be remembered for. and the third thing, i don't know if this is what it should be remembered for, but it's a takeaway for me listening to everybody is, there's incredible science out there and we need to, you know, go back and re-translate it for people. what do we know, what don't we know and what are the barriers? we really the last few years have just been, since 2011 in particular, unbelievable. dr. beyrer: yeah, magnificent. jennifer: and i think we need to
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document that in a clear way for people to understand where we are and what the potential and what the risk is of not going forward. dr. beyrer: yeah. steve: well, this has been really rich and really invaluable. we're all in your debt, everyone in this room is in your debt. i want to thank everyone who has come and been with us for the past two hours and joined in this. chris, deborah, jennifer, congratulations on these outcomes and the way you shape them. and thank you so much for coming and sharing all this. please join me in thanking our speakers. [applause] [captions copyright national cable satellite corp. 2016] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org]
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announcer: this weekend, c-span's a city tour will explore the history and literary life of michigan. we will talk with author tj gatsby and learn the role railroads played. the connection of shipping containers, moving over from places like china, indonesia. when you go to long beach california, if there is large shipping facilities, the railroads are right there on the container ships.
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they helped get it to the next road. announcer: from executive director and columnist talks about the rich history of the port, its historical importance, and the current state of the economy. >> we were a real thriving economy. we had done really well locally. in 2000 if you go by household income, michigan is one of the wealthiest states. years later we are one of the poorest states. announcer: the will visit a train depot where thomas edison worked as a young boy. we will also speak with the museum's manager. >> we have a re-creation of his chemical laboratory, where he was the first person that we know of the print the newspaper on a moving train.
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newsd access to the latest at the train offices and would get the news right hot off the presses. announcer: we will then tore the first white house -- first lighthouse in the state of michigan. onurday at noon eastern c-span's book tv. and then on american history tv at c-span3. working with our cable affiliates and visiting cities across the country. you can watch our public affairs and political programming any time at your convenience on your desktop, laptop or mobile device. go to our home page and click on the video library search bar. you can type in the name of a speaker, sponsor of a bill, or even the event topic. click on the program you would like to watch or refine with many search tools.
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if you -- if you don't want to search, our homepage has current programs ready for your immediate viewing. c-span.org is a public service of your cable or satellite provider, so if you are a c-span watcher, check it out at c-span.org. in wisconsinis this evening for a campaign rally in green bay. we will take you there live within the hour when things get underway. until then we will show you hillary clinton speaking earlier today at a conference in washington dc, where she gave remarks and took questions from reporters. this was cohosted by the national association of black journalists and the national association of hispanic journalists. hillary: good morning. i am so pleased to be here. i want to thank you for the
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invitation, the introduction, to everyone associated with nabj and nahj. i want to mark the moment because you were created in this hotel. i do not know if there are any original founders, but if there are, could you stand up and we could give you some recognition. [applause] mrs. clinton: i am delighted to thank you for the important work you do every day, and now more than ever we need you to keep holding leaders and candidates accountable, and in the tradition of past journalists like ruben salazar, we need you
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to make sure that america's front pages and nightly newscasts and online information for the great diversity of our nation. someone i had the privilege of knowing bob maynard, former "oakland tribune" owner, who once said, it is in seeing ourselves whole that we can begin to see ways of working out our differences of understanding our similarities and becoming a more cohesive nation." and that is what you do every day, helping us to see ourselves as whole. looking forward to our discussion, which i'm sure will cover a wide range of issues, but i want to say it's to focus on a challenge that does not get enough attention on the campaign trail, although i have been trying, and that is how do we expand economic opportunity for
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african-americans and latinos across america. and you know very well it has been said that when the economy catches a cold, communities of color get pneumonia. the great recession hits our whole country hard, but the toll was especially difficult for black and latino families. black wealth was cut in half. for latinos, it dropped 66%. that represented decades, even generations of hard work. and during these past 18 months, people across our country have described to me how hard it has been to get back on their feet in an economy that is still not working the way we all want to see it, and barriers of systemic racism make that even harder.
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now, i believe that president obama does not get the credit he deserves for leading us out at the great recession -- [applause] mrs. clinton: and i would like to remind people he had nothing to do with creating it in the first place. he came into office as this worst of all financial crises since the great depression was handed to him. and i think if you fairly look at the record, you have to conclude that his leadership saved us from a great depression, so as bad as things became, 9 million jobs lost, 5 million homes lost. $13 trillion in family wealth wiped out. as bad as it was, there is no telling how far down we would have gone without his leadership. so we are out of the ditch that we were in, and now we have got
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to do even more. we have got to build on the progress we've made, 15 million new jobs in the last 7 1/2 years, 20 million people now have health insurance who did not have before he became president, so we have got to have the will and the plans together to move forward. that is why i have proposed a comprehensive new commitment to african-american and latino communities to make serious, sustained investments to create more good-paying jobs, help families build and rebuild wealth, to support black and latino-owned small businesses. for me, these are not just economic issues. they are part of a long, continuing struggle for civil rights. rosa parks opened up everything on the bus. now we have got to expand
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economic opportunities so everybody can afford the fare, and we have to make sure that the bus route reaches every neighborhood and connects families with safe, affordable housing and good jobs. [applause] mrs. clinton: sylvia mendez helped desegregate our schools. now we have got to help every family afford to books, computers, and internet access that our kids need to learn in the 21st century. so in my first 100 days as president, we will work with both parties to pass the biggest investment in new, good-paying jobs since world war ii. that includes jobs in manufacturing, clean energy, technology, innovation, small businesses, and infrastructure. if we invest in infrastructure now, we will not only create jobs today, we will lay the foundation for the jobs of the future. you are going to also focus on creating jobs in communities where unemployment remains separately high after generations of underinvestment and neglect.
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i am a big fan of congressman jim clyburn's 10, 20, 30 plan, steering 10% of federal investment to neighborhoods where 20% of the population has been living below the poverty line for 30 years. we need that kind of focus, targeted investment in urban places, world places, were ever americans have been left out and left behind. we are also going to invest $20 billion in creating jobs for you people. there's a big gap here. the unemployment rate between latino and african-american youth is significantly higher than for whites. it is hard to write a resume if you have nothing to put on it. we will help him people to get that first job, to get that second job, so they can build a good middle-class life that will
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give them and their families a better future. we are also going to do more to help black and latino entrepreneurs get access to capital so they have a real chance at turning their ideas into thriving businesses. it is not only good for those entrepreneurs. it is good for their families, workers, and communities. additionally, as part of our work to reform the criminal justice system, we will help people succeed when they return home from jail or prison. we are going to ban the box so they can be judged by their skills and talents, not by their past, and we will dedicate $5 billion to provide training and support to returning citizens so they can get a good-paying job. and in my first 100 days, i'm going to introduce legislation for comprehensive immigration reform with a path to citizenship, as not only the
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right thing to do. every independent analysis shows it will add hundreds of billions of dollars to our economy. it will also keep families together. we need to bring hard-working people out of the shadows. america has always been a place where people from around the world work hard and apply their talents to american growth and innovation in pursuit of their own dreams. we are going to do everything we can to get this done. we need to build an economy in the future that every american can be proud of and be a part of. an economy that works for everyone, not just those at the top. that will be my mission as president. these are just some of the highlights of our plan. i hope you will go to my website, hillaryclinton.com to read the details, including how we are going to pay for everything i proposed.
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and of course, i hope you will compare what i am proposing to what my opponent is talking about. in [laughter] mrs. clinton: i hear one measure you could use for that comparison. an independent economist recently calculated that if my agenda for jobs and growth is put into place, our economy would create at least 10.4 million jobs within four years. we actually think it could be more than that. now, this economist also ran the numbers on donald trump, including his disastrous and inhumane plan to round up and deport millions of hard-working immigrants. the result, according to the economic advisor for john mccain during his 2008 run for the presidency, the result of trump's plans would be a lengthy recession with 3.4 million jobs lost.
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now, of course, donald trump's problems go beyond economics. at every turn, he stokes division and resentment. he says horrible things about one group of americans after another. he is harkening back to the most shameful chapters of our history and appealing to the ugliest impulses of our society. you know the list. you have reported on it. he started this campaign by describing mexican immigrants as criminals and rapists. he retweets white nationalists. he says a distinguished federal judge cannot be trusted because he is of mexican heritage. he talks about banning muslims from coming to the united states, a land built on religious freedom, and, yes, he also talks about curtailing press freedom as well.
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we need to stand out as a country and say that donald trump does not represent who we are and what we believe. that is what my campaign, what tim kaine and i and everyone supporting us is doing every day, and we're going to keep at it, because i believe with all my heart that america is better than this. america is better than donald trump. we just launched an all-spanish twitter account because we want to bring as many americans as possible into this conversation. we have opened offices in every state because we want to compete everywhere. we want to bring our message and our vision to all corners of our country. but we cannot do it alone. everyone, republican, democrat, an independent needs to stand up and speak out. i think journalists have a special responsibility to our democracy in a time like this.
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as ida wells once said, people must know before they can act, and there is no educator to compare to the press. many of you are showing the way. it is a badge of honor when jorge ramos gets thrown out of a press conference for challenging donald trump. [applause] mrs. clinton: or when and other news organizations get gets and for reporting what he says. as jorge said, the best journalism happens when you take a stand, when you do not stand for justice. i hope you will keep calling it like you see it. keep holding us all accountable. i have laid out all these plans, and i am well aware that i have been sometimes made fun of for putting out these plans about the economy and education and criminal justice reform and health care and gun safety
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measures and all the rest of it. but i do have this old-fashioned idea, when you run for president, you ought to tell the voters of america what you would do as president. so i'm going to keep telling you what i would do because i what you to hold me accountable, press and citizens alike, because the stakes are as high as they have ever been in our lifetime. and we all have to do our part. so thank you for what you do every day. thank you for inviting me to address you today, and i look forward to taking some of your questions. thank you all very much. [applause] >> please welcome the moderator, a white house correspondent for nbc news, and a national correspondent for telemundo. >> thank you. [applause]
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good afternoon to all of you. what an honor to be here, and it is fantastic to see so many people gather here for this great conversation we are going to have with secretary clinton. secretary clinton, thank you for being here. usually i am on the campaign trail with her. so it is great to be able to have this conversation this afternoon. madam secretary, thank you for accompanying us. i think we should get right to it. you alluded to the topic i wanted to ask you about. people are concerned about the economy, about education. they also believe in trustworthiness. i want to start with the topic that i believe will result, tell the future of it after this election. it is immigration reform. many latinos are discouraged by the lack of immigration reform.
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they believe their vote has been taken for granted. we know what your position is. what i would like for you to do is to walk us through the steps -- how will you get immigration reform, having that president obama was not able to do, so that latinos can't believe that something is going to happen, that their vote is not taken for granted, considering that the house will remain under republican control. mrs. clinton: a great question and one that i have given much thought to, because i am determined that we are going to achieve comprehensive immigration reform with a path to citizenship. here is how i see it. we are going to start immediately. i want this to be a clear high priority for my administration. we will be prepared to introduce as efficient as quickly as we can do so.
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i am hoping that the outcome of the election, which i am working hard to ensure a victory, will send a clear message to our republican friends that it is time for them to quit standing in the way of immigration reform. if you remember, after the 2012 election, the republican national committee did what they call an autopsy of their loss and concluded that they could not continue to deny the importance of immigration reform, and they urged republicans running for office to get on board. now, that has not turned out the way that they seemed to have hoped. we have instead a republican nominee who has been virulently anti-immigrant.
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there is nothing like winning to change minds. we have a good chance of having a democratic senate if everybody does what i would hope they would do and vote for democratic candidates for the senate. i believe we will pick up some seats in the house and, at least if not take it back, narrow the numbers. if we move in the senate and then we demand that there be a vote in the house -- because i am convinced that if the bipartisan bill that had been achieved in the senate -- remember, when marco rubio was for it and people worked hard and achieved it -- if it had been allowed to come for a vote in the house, it would have passed. so i view the political landscape as increasingly favorable to us making this happen. i will also defend the president's executive actions.
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i like you was disappointed with the supreme court decision, but remember what it did -- it sent attempt case back to be tried. it did not determine the case. they are still alive. donald trump has said one of his first acts as president would be to eliminate every executive order that president obama has signed, including those on immigration issues. workl defend them while i vigorously for immigration reform. i've proposed an opposite immigration affairs for the white house. so that we are able to answer questions and provide information and help people. i will take a very hard look at the deportation prior to, my head priorities are

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